Healthcare Provider Details

I. General information

NPI: 1720225410
Provider Name (Legal Business Name): LAKESIDE OB/GYN AND PELVIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2009
Last Update Date: 01/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 JESSE JEWELL PKWY SE SUITE D
GAINESVILLE GA
30501-3852
US

IV. Provider business mailing address

PO BOX 2994
GAINESVILLE GA
30503-2994
US

V. Phone/Fax

Practice location:
  • Phone: 678-450-4757
  • Fax: 678-450-4758
Mailing address:
  • Phone: 678-450-4757
  • Fax: 678-450-4758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA LYNN MASSEY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 678-450-4757